Neonatal Drug Withdrawal · The neonatal abstinence syndrome has been treated with methadone. The prolonged 0 plasma half-life of methadone (t,. = 26 hours) makes difficult the adjustment

PEDIATRICS (ISSN 0031 4005). Copyright © 1983 by the

American Academy of Pediatrics.

0 Committee on Drugs

AMERICAN ACADEMY OF PEDIATRICS 895

Neonatal Drug Withdrawal

Symptoms of neonatal drug withdrawal consist

of: W = wakefulness; I = irritability; T = tremu-

lousness, temperature variation, tachypnea; H =

hyeractivity, high-pitched persistent cry, hypera-

cusia, hyperreflexia, hypertonus; D = diarrhea, dia-

phoresis, disorganized suck; R = rub marks, respi-

ratory distress, rhinorrhea; A = apneic attacks,autonomic dysfunction; W = weight loss or failureto gain weight; A = alkalosis (respiratory); L =

lacnimation (Fig 1); also, hiccups, vomiting, stuffy

nose, sneezing, yawning, photophobia, twitching,

myoclonic jerks, opisthotonos, or seizures.

When these symptoms are seen in a newborn

infant, the physician should consider a diagnosis of

withdrawal from maternal drugs. Narcotics re-

ported to cause these symptoms in the neonate are

heroin,’ methadone,2 meperidine,3 morphine,’ co-

deine,4 pentazocine,5’6 and pnopoxyphene.7 A glos-0 sary of drugs is provided in Fig. 2.

The onset of symptoms may be present at birth

or may begin within four days of delivery. In some

instances, symptoms may not become obvious until

10 days of age. This depends upon the drug the

infant was exposed to in uteno and the pharmaco-

kinetic excretion of the drug. Subacute symptoms

of narcotic drug withdrawal may last for 4 to 6

months.8

Rosen and Pippenger9 have demonstrated that

infants born to mothers maintained on methadone

do not begin to manifest withdrawal symptoms

until the plasma level is less than 0.06 �g/mL. In

utero exposure to multiple drugs may cause a bi-

phasic pattern of withdrawal symptomatology in

the neonate.’#{176} Polydrug abusers frequently use as

many as two to five drugs in combination; these

might include phenobarbital, diazepam, marijuana,

pentazocine, tnipelennamine, phencyclidine, and

codeine.” A physician who is unaware ofa mother’s

drug ingestion may initially make an erroneous

diagnosis of colic in the infant; therefore, a detailed

maternal drug history should be obtained, including

prescription and nonprescription drugs received,

0

social habits of the parents, and whether the mother

is breast-feeding. In the event a negative drug his-

tory is obtained but infant symptomatology is con-

sistent with drug withdrawal, a drug screen should

be performed on the mother’s or infant’s blood and

urine. Recently, screening of meconium for drugs

has been reported to produce greater confirmation

of fetal drug exposure than screening of urine.’2

TREATMENT OF NARCOTIC WITHDRAWALFROM MATERNALLY ACQUIRED DRUGS

Treatment of the neonate should be primarily

supportive, as unjustified pharmacologic adminis-

tration will prolong hospitalization and subject the

infant to additional exposure to drugs that are not

indicated. Supportive care includes swaddling to

decrease sensory stimulation; frequent small feed-

ings of hypercalonic (24 cal/oz) formula to supply

the additional caloric requirements; and observa-

tion of sleeping habits, temperature stability,

weight gain or loss, or change in symptomatology

which might suggest another disease process taking

place (ie, infection). The clinical symptoms in 30%to 50% of infants who manifest drug withdrawal

may be treated in the above manner without use of

pharmacologic therapy.

Excess weight loss may represent inadequate pro-

vision of calories rather than the need for phar-

macologic therapy. Besides the caloric expenditure

caused by increased activity, crying, and decreased

sleep, calories may be lost through vomiting, drool-

ing, and diarrhea. Hyde et al’3 have shown that

infants withdrawing from maternal narcotics have

an increased 02 consumption at the tissue level,

which increases caloric need. Caloric intake should

be calculated daily in order to provide the 150 to

250 cal/kg/24 h necessary for proper growth in

babies suffering withdrawal from narcotics.14”5

Each nursery should adapt one of the abstinence

scoring methods to judge the need for drug therapy

as nurses and doctors often become sympathetic

with the jittery and frantic behavior observed in

the infant and are prone to begin drug therapy for

subjective reasons.’6’8 An abstinence scoring sheet

results in the use of more objective criteria for

by guest on November 19, 2020www.aappublications.org/newsDownloaded from

w = WakefulnessI = Irritability

T = Tremulousness, temperature variation, tachy-pnea

H = Hyperactivity, high-pitched persistent cry, hy-peracusia, hyperreflexia, hypertonus

D = Diarrhea, diaphoresis, disorganized suckA = Rub marks, respiratory distress, rtiinorrheaA = Apneic attacks, autonomic dysfunctionW = Weight loss or failure to gain weightA = Alkalosis (respiratory)L = Lacnmation

Fig 1. Symptoms of neonatal drug withdrawal.

GENERIC NAME

amitriptyline

chlordiazepoxidechlorpromazineclomipramineclonidinediazepamdiphenhydramineethchlorvynolhydroxyzineimipraminelithium

mependinemeprobamatemethadonepentazocinephenobarbital

propoxyphenetheophylline

trifluoperazine

TRADE NAMES

Elavil, Endep, Enovil,SK-Amitnptyline

Librium

Thorazine(investigative drug)CatapresValiumBenadrylPlacidylAtarax, Orgatrax, VistanlImavate, SK-Pramine, TofranilEskalith, Uthane, Lithobid,

Lithonate, LithotabsDemerolEquanil, Meprospan, MiltownDotophineTalwinLuminal, SK-Phenobarbital,

Sedadrops, SolfotonDarvon, Dolene, SK-65Bronkodyl, Elixophyllin,

Somophyllin-T, Slo-Phyllin,Theostat, Theolair,Theophyl

Stelazine

Fig 2. Glossary of drugs. Trade names are listed inaccordance with the AMA Drug Evaluation, ed 5 (Chi-cago, American Medical Association), 1983.

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896 NEONATAL DRUG WITHDRAWAL

determining when pharmacologic treatment is nec-essary and whether a drug dose should be advancedor decreased. Supportive cane in the form of intra-

venous fluids and replacement electrolytes may benecessary to stabilize the infant’s condition in the

acute phase without the need for pharmacologicintervention.

Indications for drug treatment include vomitingand diarrhea that result in excessive weight loss or

dehydration, inability of the infant to sleep, feverunrelated to infection, and seizures. It is essentialthat infection, hypoglycemia, hypocalcemia, hypo-magnesemia, hyperthyroidism, CNS hemorrhage,

and anoxia be ruled out as the etiology for the

symptoms. The history of a drug abuser mother

should be checked for evidence of past hepatitis on

sexually transmitted disease. oPHARMACOLOGIC AGENTS USED TO TREAT

NARCOTIC WITHDRAWAL

Narcotics

Paregoric. Many physicians prefer paregoric for

therapy of the narcotic abstinence syndrome be-

cause of the ease in administration of the drug.

Infants treated with paregoric for narcotic with-

drawal symptoms have a more physiologic sucking

pattern, higher nutrient consumption, higher pen-

centage of sucking time, greater sucking pressureexerted at nursing, and more weight gain thaninfants treated with diazepam or phenobarbital.’9

Paregoric contains anhydrous morphine (0.4 mg/mL). In addition, it contains opium alkaloids whichconsist of isoquinoline derivatives (nancotine and

papavenine) which are antispasmodics and phen-

anthrene derivatives (morphine and codeine) whichare analgesics and narcotics. Paregoric containscamphor, a CNS stimulant that is eliminated from

the body slowly because of its high lipid solubilityand the need for glucuronic conjugation for urinaryexcretion. Paregoric contains a high concentration

ofalcohol (44% to 46%), which is a CNS depressant,

and anise oil, which may cause habituation. Benzoicacid (4 mg/mL), an oxidative product of benzyl

alcohol, is present in paregoric. Severe acidosis,CNS depression, respiratory distress, hypotension,

renal failure, seizures, and death have been reported

to occur in small premature infants who receive

benzyl alcohol in amounts of 99 to 234 mg/kg/24

h.2022 Glycerine is another component.

The dose of paregoric administered to a full-term

infant for treatment of neonatal narcotic with-

drawal is from 0.2 mL (0.08 mg morphine equiva-lent) to 0.5 mL (0.2 mg morphine equivalent) per

dose every 3 to 4 hours until the symptoms of

withdrawal are controlled. A neonatal abstinence

score is helpful in determining the need for increas-ing or decreasing the dose. The dose of paregoric

should be tapered after symptomatology has been

stabilized for three to five days.Tincture of Opium. The United States Pharma-

copeia preparation of tincture of opium also con-

tains opiate alkaloids and morphine (10 mg/mL)

but in a weaker alcohol preparation (17% to 21%).There is concern about stocking tincture of opiumin hospital pharmacies because doctors and nurses

may inadvertently mistake this preparation for par-

egonic and thus administer an excess dose of opium.A 25-fold dilution of tincture of opium contains the



same concentration of morphine equivalent as par-

egoric (0.4 mg/mL morphine equivalent) without

the additives (camphor, anise oil, benzoic acid, or0 glycerine) found in paregoric. A recent study has

shown that the diluted solution remains stable for

at least 2 weeks (S. Segal, unpublished data, 1983).

Because of the danger of mistaking tincture of

opium for paregoric, tincture of opium should be

dispensed to the nursery only in a dilution that

contains a concentration of morphine equivalent to

the concentration in paregoric. A suggested name

for the preparation is “neonatal opium solution.”

Diluted tincture of opium should be administered

according to the same morphine equivalent dosage

schedule used for paregoric.

Morphine. In the past, parenteral morphine hasbeen used to treat the severe vasomotor collapse

observed in infants with heroin withdrawal.’5

The parenteral form of morphine contains so-dium bisulfite (1 mg/mL), which has been reported

to produce an anaphylactic reaction consisting of

prunitus, flushing, and acute wheezing in older pa-

tients.24 The parenteral form of morphine also con-

tains phenol (5 mg/mL). Absorption of phenol via

the skin has been associated with jaundice in small

infants.25 The dose of phenol that produces hyper-

bilirubinemia is not known. The 8-mg/mL ampul

of morphine also contains 7 mg/mL (0.12 mEiJ

mL) of sodium chloride. Because morphine is usedin such small doses, these additives may not have

a significant effect on the infant.

An oral preparation of morphine (2 and 4 mg/

mL), which contains no additives and less alcohol

than paregoric (10%), is now available. Oral mor-

phine has less analgesic effect than the same par-

enteral dose. To date there have been no studies in

which morphine preparations with morphine equiv-

alents similar to paregoric have been used to treat

neonatal narcotic withdrawal. Oral morphine doses

should be calculated to deliver to the full-term

infant the same quantity of morphine equivalent

usually supplied in paregoric.

There is some concern regarding safety in use of

opiate preparations in neonates due to their marked

respiratory depressant effect. This concern is ac-

centuated in the report by Mitchell et al26 of life-

threatening reactions in infants less than 3 months

of age who were premedicated with morphine. They

found that morphine doses of 0.1 mg/kg may cause

respiratory cessation in non-narcotic-habituated

infants. Infants manifesting narcotic withdrawal

will be more refractory to this dose.

Methadone. The neonatal abstinence syndromehas been treated with methadone. The prolonged

0 plasma half-life of methadone (t,. = 26 hours)makes difficult the adjustment of the dose of meth-

adone in the infant during decreasing require-

ments.9 The multiple-dose vial of methadone con-

tains chlorobutanol (0.5 mg/mL), which is a seda-

tive, and 8% ethyl alcohol in the oral form.

Neuroleptics

Diazepam. Rapid suppression of narcotic with-drawal symptoms has been observed in infants

treated with diazepam (1.0 to 2 mg every 8 hours).

The newborn infant has a limited capacity to me-

tabolize and excrete diazepam. Total elimination of

diazepam and its metabolites may take 1 month or

more.2’ The infant’s suck reflex may also be de-

pressed, and late-onset seizures have been observed

in infants treated with diazepam.28 Panentenal di-azepam contains benzyl alcohol (1.5%) and sodium

benzoate (5%), which may displace bilirubin for

conjugation and excretion; therefore, use of diaze-

pam is contraindicated in a jaundiced infant or a

premature infant.29 Nathenson et al3#{176}measured

albumin binding capacities of addicted infants

treated with diazepam and found some decrease in

albumin binding capacity.

In addition, parenteral diazepam contains ethyl

alcohol (10%) and significant quantities of propyl-

ene glycol (40%). Cerebral and hepatic dysfunction

and hyperosmolality with an osmolar gap have been

reported in infants receiving large quantities (10

mL/24 h) of parenteral multivitamins which con-

tam 30% propylene glycol.31’32

Chlorpromazine. The CNS and gastrointestinalsymptoms produced by narcotic withdrawal are

controlled by chlorpromazine. A dosage of 2.2 to 3

mg/kg/24 h in divided doses every 6 hours intra-

muscularly or orally has been used in infants. Oc-

casionally, hypothermia may develop. The abnon-

malities in rapid eye movement (REM) sleep ob-

served during withdrawal are not alleviated by

chlorpromazine. Some chlorpromazine metabolites

are eliminated slowly oven an 18-month period in

adults; therefore, a prolonged excretion time may

be anticipated in the neonate.” Chlorpromazine

contains sodium chloride (6 mg/mL), sodium bis-

ulfite, and sulfite (2 mg/mL). The multidose vial

contains henzyl alcohol (2%).

Sedatives

Phenobarbital. Hyperactive behavior in the in-fant who manifests narcotic withdrawal is modified

by administration of phenobarbital, but the drug

does not relieve the gastrointestinal symptoms.

Large doses of phenobanbital may significantly sup-

press the CNS of the infant, may impair the suck

reflex, and may delay the bonding between motherand infant. Elixirs of phenobanbital contain 14% to25% alcohol. The parentenal forms contain pnopyl-


0�

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0


ene glycol (67.8%), ethyl alcohol 10%, and benzyl

alcohol 1.5%. The therapeutic blood level of pheno-

barbital necessary for control of narcotic with-

drawal symptoms is not known. Finnegan et al34

used a neonatal loading dosage of 16 mg/kg/24 h of

phenobarbital that produced blood levels of 20 to

30 sg/mL, which effectively controlled symptoms

of narcotic withdrawal.34 A blood level should be

obtained 24 to 28 hours later and the maintenance

dose adjusted according to the infant’s symptoma-

tology as determined by the abstinence score and

the phenobarbital plasma level. Finnegan et al34

reported that maintenance doses of 2 to 8 mg/kg/

24 h were required to control withdrawal symptom-

atology and maintain phenobarbital plasma levels.

After the infant’s condition has stabilized, the

maintenance dose should be decreased to allow the

drug level to decrease by 10% to 20% per day.

Antihypertensive Agent

Clonidine has been shown to reduce withdrawal

symptoms in adult opiate addicts. It has been ad-

ministered to two neonates withdrawing from ma-

ternal methadone.3� More data are required to de-

fine the role of clonidine in the treatment of neo-

natal withdrawal.

GENERAL CARE OF THE NEONATE

Medications should be administered at the time

of feeding in order to limit the number of times the

infant is disturbed. When vomiting is a problem,

oral drugs may be administered 30 minutes before

a feeding. After a stabilizing dose is attained, the

drug dose should be maintained so that the infant

sleeps well, eats effectively, and gains weight for a

period of three to five days; then the dose may be

tapered. The physician may be hesitant to taper the

dose of medication; this hesitancy may result in

prolonging the infant’s hospitalization and drug

therapy. The abstinence scoring sheet and changes

in weight may be used to determine objectively the

rapidity with which drug therapy should be tapered.

Irritability and tremors should not be used as a

criteria for continued drug administration as sub-

acute symptoms of irritability, tremors, and poor

sleeping patterns may last until age 6 months.8

FOLLOW-UP CARE

Optimal treatment of the infant requires a team

approach by a physician who is knowledgeable of

the symptoms and therapy of neonatal withdrawal

and who communicates with the parents; a nursing

staff willing to tolerate the symptoms of the infant

and willing to incorporate the parents into the totalcare of the infant; and a social service worker who

can win the confidence of the parents and thus

determine the parents’ ability to care for the infa�itafter discharge from the hospital.

The period of treatment in the hospital is the

time when both parents learn to help care for their

infant. The infant who is withdrawing from a drug

is a very difficult infant with whom to bond andwith whom to live on a 24-hour basis; the caretakers

should be provided constant emotional support.

Participation of the parents in the care of their

infant in the hospital assists them in gaining con-

fidence in interpreting the infant’s symptoms and

decreases the demands for medication sought forsubacute symptoms of withdrawal once the infant

is discharged from the hospital. No infant born to

a known drug abuser should be discharged home on

drugs as the parents may sympathetically use thedrug for a longer period of time than is indicated

or they may use the drug to supply their own needfor drug replacement. Parents of infants who are

withdrawing from drugs prescribed to the mother

for medical purposes have strong guilt feelings and

tend to overreact to the symptoms demonstrated

by the infant.

Recurrence of withdrawal symptoms in the infant

may develop after discharge from the hospital. It is

essential that the hospital staff establish rapport

with the parents so that they will return the infant

to the hospital for treatment in this event. Sudden

infant death syndrome (SIDS) and acquired im-munodeficiency syndrome (AIDS) have been ob-

served in infants born to methadone and heroin

users.�bl9 In one study, the incidence of SIDS was

correlated with the severity of the infants’ with-

drawal symptoms while in the nursery.4#{176}

There should be a long-term follow-up of thephysical and mental development of any infant whois withdrawing from maternal drugs.

AGENTS PRODUCING SYMPTOMS SIMILARTO THOSE OF NARCOTIC WITHDRAWAL

Other maternal medications may produce in the

infant a symptom complex similar to that of nan-

cotic withdrawal (Table 1). The symptoms observedin the infant may represent withdrawal or intoxi-

cation and may last for variable periods of time

(days to months).

In general, infants who demonstrate intoxication

from maternal drugs require mostly supportive care

during the period of excretion of the drug rather

than administration of additional pharmacologicagents that the infant must metabolize and excrete.In cases of severe symptomatology, drug therapy

may be indicated for patient comfort.

Infants who manifest adverse reaction to mater-nal psychotropic agents and who require pharma-


TABLE 1. Nonnarcotic Maternal Drugs That Cause Neonatal Psychomotor Behavior Consistent with That Produced

by Withdrawal (W) or Intoxication (I)*

Drug Symptoms Duration of Symptoms W/I Reference

Barbiturates

2#{189}mo, 5 d-Rx I 50,51

0

Desmethylim-ipramine

Diazepam

Diphenhydra-

0 mineEthchlorvynol

Glutethimide

Hydroxyzine

Imipramine

52

Phencyclidine

Theophylline

0

45

* Abbreviations used are: HR, heart rate; RR, respiratory rate; Rx, refers to infant treated with pharmacologic agents

and the natural course of the symptoms may have been shortened.

899

Alcohol Hyperactivity, crying, irritability; poor suck,

tremors, convulsions, onset of symptoms atbirth, poor sleeping pattern, hyperphagia,diaphoresis

Amitniptyline Tremors, poor sleeping patterns, feeding diffi-culty, abdominal pain

Irritability, severe tremors, hyperacusis, exces-sive crying, vasomotor instability, diarrhea,restlessness, � tone, hyperphagia, vomiting,

disturbed sleep; onset 1st 24 h of life or at10-14 d of age

Bromide Lethargy, dilated pupils, hypotonia, hyper-tonus, high-pitched cry, feeding difficulty, �reflexes

Chlordiazepox- Irritability, tremors; symptoms may start at 21ide d

Chlorpromazine Extrapyramidal dysfunction, intention tremor,opisthotonos, mask-like facies; onset 1st 24-36 h

Clomipramine Hypothermia, cyanosis, tremors; onset 12 h ofage

Breathelessness, cyanosis, � ilR, I RR, diapho-resis, irritability, feeding difficulty, weightloss

Hypotonia, poor suck, hypothermia, apnea,?hypertonia, hyperreflexia, tremors, vomit-

ing, hyperactivity, tachypnea, (mother mul-tiple drug therapy)

Tremulousness, diarrhea. Onset 5 d of age

??Lethargy, jitteriness, hyperphagia, irritabil-

ity, poor suck, hypotonia, (mother receivingmultiple-drug therapy)

I tone, tremors, opisthotonos, high-pitched cry,hyperactive, irritable, “colic”

Tremors, irritability, hyperactivity, jitteriness,shrill cry, myoclonic jerks, hypotonia, I RR,

I HR, feeding problem, clonic movements(Mother receiving multiple therapy)

Cyanosis, respiratory distress, vasomotor insta-bility, irritability, hypokinesia, convulsions,jerky movements, � RR, autonomic dysfunc-tion, hypoactivity, belly dance movements ofabdomen before voiding

Lithium Respiratory distress, lethargy, cyanosis, poorsuck, hypotonia

Local anesthe- Acidosis, convulsions, � BR, opisthotonos, neu-sia rologic depression, apnea, spontaneous

movement, � responsiveness, I reflexes, ab-normal oculomotor reflexes, death, hypo-tonia, fixed pupils

Magnesium sul- Respiratory depression, hypotonia, convul-

fate sions, death

Meprobamate Irritability, tremors, poor sleep patterns, ab-dominal pain

Jitteriness, hypertonia, vomiting, lethargy, yen-tical nystagmus

I HR, gagging, vomiting, jitteriness, opistho-tonos

Trifluoperazine ? Late-onset, extrapyramidal dysfunction

18 mo w 42-44

9mo I 45

4-6 mo-Rx W 46-49

9 mo, 1#{189}mo-Rx W

9 mo, 12 wk-Rx I 41,53

4d-Rx W 54

10-30d I 55

8 mo, 10-66 d-Rx I 56,57

9d-Rx I 58

? lOd-Rx IandW 59

6mo W 60

Swk-Rx W 61

?6d I 62

lOd I 63,64

Related to Rx, excreted I 65-69

1st 24 h

Depends on Rx I 70,71

9 mo, 3 mo-Rx W

18 d + Rx, 8 da + Rx I 72,73

2d I 74

9 mo, 2-3 d-Rx I 53,57


TABLE 2. Pharmacologically Active Excipients inProducts Used to Treat Neonatal Withdrawal*

* Abbreviations used are: P, parenteral; po, per os (by

mouth).

0

0

0

REFERENCES

1. Cobrinik RW, Hood RT Jr, Chusid E: The effect of maternalnarcotic addiction on the newborn infant. Review of theliterature and report of 22 cases. Pediatrics 1959;24:288

2. Blatman S, Lipsitz PJ: Children of women maintained onmethadone: Accidental methadone poisoning of children, inFourth National Conference on Methadone Treatment, San

Francisco, Jan 8-10, 1972. New York, National Associationfor the Prevention of Addiction to Narcotics, Publisher,

1972, p 1753. Fisch GR, Henley WL: Symptoms of narcotic withdrawal in

a newborn infant secondary to medical therapy of themother. Pediatrics 1961;28:852

4. Mangurten HH, Benawra R: Neonatal codeine withdrawalin infants of nonaddicted mothers. Pediatrics 1980;65:159

5. Goetz RL, Bain RV: Neonatal withdrawal symptoms asso-

ciated with maternal use of pentazocine. J Pediatr1974;84:887

6. Dunn DW, Reynolds J: Neonatal withdrawal symptoms

associated with “T’s and blues” (pentazocine and tripelen-namine). Am J Dis Child 1982;136:644

7. Tyson HK: Neonatal withdrawal symptoms associated withmaternal use of propoxyphene hydrochloride (Darvon). JPediatr 1974;85:684

8. Wilson GS, Desmond MM, Verniaud WM: Early develop-

ment of infants of heroin-addicted mothers. Am J Dis Child1973;126:457

9. Rosen TS, Pippenger CE: Disposition of methadone and its

relationship to severity ofwithdrawal in the newborn. AddictDis 1975;2:169


Excipients Generic Name

Anise oil Tincture of paregoric (po)

Benzoic acid and sodium Diazepam (P)benzoate Tincture of paregoric (po)

Benzyl alcohol Chlorpromazine (P)Diazepam (P)Phenobarbital (P)

Camphor Tincture of paregoric (po)

Chlorobutanol Methadone (P)Ethyl alcohol Diazepam (P)

Methadone (po)Morphine (P and po)Opium tincture (po)Phenobarbital (P and po)Tincture of paregoric (po)

Opium alkaloids Opiate tincture (po)Tincture of paregoric (po)

Propylene glycol Diazepam (P)Phenobarbital (P)

Sodium bisulfite and Chlorpromazine (P)sulfite Morphine (P)

cologic therapy are best treated with phenobarbital

as it produces fewer adverse effects than the use of

neuroleptic agents in the neonate. Diphenhydra-mine has been used in one infant thought to be

having an adverse reaction to a phenothiazineagent.4’

Infants who are withdrawing from maternally

acquired barbiturates should be administeredphenobarbital if pharmacologic treatment is nec-

essary. The therapeutic plasma level necessary to

treat barbiturate withdrawal is not known. Thecalculated loading dose (10 to 15 mg/kg/24 h) ofphenobarbital should be given in divided doses over

a 24-hour period and followed by a maintenancedose of 3 to 5 mg/kg/24 h. Blood levels should be

monitored to prevent intoxication. Infants rarelyrequire phenobarbital administration for longerthan 6 to 8 weeks.

SUMMARY

The Committee on Drugs of the American Acad-emy of Pediatrics recommends that thoughtful con-

sideration be given to the need for administration

of pharmacologic agents to newborn infants who

have symptoms of drug withdrawal. Supportive care

should be the first line of therapy, and objective

methods such as an abstinence scoring sheet should

be used to determine the need for instituting andthen discontinuing pharmacologic treatment.

When appropriate, specific drug therapy should be

used for treatment of withdrawal symptoms (ie,

phenobarbital for phenobarbital withdrawal and

opiate for opiate withdrawal). Attention should be

given to potential adverse effects in the infant

resulting from excipients present in many of the

drugs (Table 2).The information provided herein should serve as

a guide for the physician in providing supportive

care and pharmacologic treatment of the infant

suffering from drug withdrawal.

COMMITTEE ON DRUGS, 1982-1983

Albert W. Pruitt, MD, Chairman

Walter R. Anyan, Jr, MD

Reba M. Hill, MD

Ralph E. Kauffman, MDHoward C. Mofenson, MD

Harvey S. Singer, MD

Stephen Spielberg, MD, PhD

Liaison Representatives

John C. Ballin, PhD

Martha M. Freeman, MD

Jennifer Niebyl, MD

Dorothy L. Smith, PharmD

Sam A. Licata, MD

Godfrey Oakley, MD

Steven Sawchuk, MD

Louis Farchione, MD

AAP Section Liaisons

Earl J. Brewer, MD

John A. Leer, MD



10. Desmond MM, Wilson GS: Neonatal abstinence syndrome:

Recognition and diagnosis. Addict Dis 1975;2:113

11. Chasnoff IJ, Hatcher R, Burns WJ: Polydrug- and metha-

done-addicted newborns: A continuum of impairment. Pe-O diatrics 1982;70:210

12. Ostrea EM Jr, Kroll DW: Meconium-The ideal specimen

for drug screen in infants born to known or suspected drugabusers, abstracted. Pediatr Res 1983;17:153A

13. Hyde WH, Scharnberg JT, Rudolph AJ: Oxygen consump-

tion in infants of narcotic addicts, abstracted. Pediatr Res

1980;14:467

14. Wilson GS: Somatic growth effects of perinatal addiction.

Addict Dis 1975;2:33315. Hill RM, Desmond MM: Management of the narcotic with-

drawal syndrome in the neonate. Pediatr Clin N Am1963;10:67

16. Finnegan LP, Kron RE, Connaughton JF, et al: Assessment

and treatment of abstinence in the infant of the drug-dependent mother. mt � Clin Pharmacol 1975;12:19

17. Lipsitz PJ, Blatman 5: Newborn infants of mothers on

methadone maintenance. NY State J Med 1974;74:994

18. Ostrea EM, Chavez CJ, Stryker JC: The care of the drugdependent woman and her infant. Lansing, MI, MichiganDept of Public Health, Publisher, 1978

19. Kron RE, Litt M, Phoenix MD, et al: Neonatal narcotic

abstinence: Effects of pharmacotherapeutic agents and ma-

ternal drug usage on nutritive sucking behavior. J Pediatr1976;88:637

20. Gershanik J, Boecler B, Ensley H, et al: The gasping syn-drome and benzyl alcohol poisoning. N Engi J Med1982;307:1384

21. Brown WJ, Buist NRM, Gipson HTC, et a!: Fatal benzyl

alcohol poisoning in a neonatal intensive care unit. Lancet1982;1:1250

22. American Academy of Pediatrics, Committee on Fetus and

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A DIFFERENCE IN THE FAMILY

Sometimes outsiders accept [a disabled] child but expect unreasonable sac-

nifices of his parents. Lucy Forrest described . . . the ways that neighbors and

strangers helped her and her husband implement a demanding treatment plan

for Christopher. Volunteers came in daily to ‘pattern’ the little boy; contnibu-

tions helped the family finance bimonthly trips to a distant clinic. But this

support given freely during the early months when the Forrests devoted every

minute to their baby, almost evaporated when they started to pick up thethreads of their previous life. Specifically, when Lucy began to repaper their

new house, some of the volunteers acted shocked and even hostile. The reactionwounded the young couple; they felt the world exacted a heavy price for its

sympathy, asking that they devote their entire lives to their hurt son and give

up the pleasures others take for granted.Submitted by Student

From Featherstone H: A Difference in the Family. New York, Basic Books, 1980.

0

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Neonatal Drug Withdrawal · The neonatal abstinence syndrome has been treated with methadone. The prolonged 0 plasma half-life of methadone (t,. = 26 hours) makes difficult the adjustment